Rebecca is a 34-year-old white woman who was admitted initially for detoxifi- cation from alcohol. She previously had been living with her boyfriend of 5 years, but her drinking had been a point of contention in their relationship for the past year, and he had finally ended the relationship and moved out. Unable to pay their rent on her own and having recently lost her job, she was forced to move back in with her parents, with whom she had not lived since she was a col- lege sophomore. Her parents, alarmed at her drinking and the recent changes in her life, were able to convince her to start cutting down on her own. However, she experienced a seizure 3 weeks prior to presentation and was taken to the emergency department, where she had a negative head computed tomography (CT) scan and was sent home. She resumed drinking at her previous level for the next 3 weeks, until she consented to be brought to the hospital for admission to the inpatient detoxification unit. After completing an uneventful course of detoxification, she was transferred to the rehabilitation unit. This was her first inpatient detoxification and rehabilitation, although she had done an outpatient detoxification approximately 4 years earlier before going to stay in a sober living house for 3 months. While on the rehab unit, Rebecca participated in group therapy, 12-step meetings, and individual therapy with her counselor. Her coun- selor noted that she appeared very anxious and fidgety in sessions and would easily become tearful; other counselors reported that she was quiet in group and also felt that she appeared anxious. Rebecca was seen by the psychiatrist on the unit for a formal evaluation during which the following history was elicited.
Rebecca reported having her first drink at age 14 while at a party with her friends. She recalled nothing special about this first experience, neither partic- ularly liking nor disliking alcohol, but she had continued to drink “socially” through high school, mostly on the weekends. In college her drinking started to escalate somewhat, and she would binge more heavily on the weekends and would drink occasionally during the week as well. She remembered her drinking as not being significantly more than that of her peer group during weekend par- ties but admitted that most of her friends did not drink during the week. She also recalled one instance when she was taken to the student health center after she had passed out during a party and her friends were unable to rouse her. Her schoolwork was not affected, however, and she graduated with honors. She then moved to the West Coast to work in communications at a public relations firm. Rebecca stated that it was at this time that she noticed a significant increase in her drinking. Drinks after work with coworkers were a frequent occurrence during the week, and Rebecca attended happy hours at least 3 days a week in addition to drinking on the weekends with her friends. Her work was enjoyable but also stress- ful, and she found herself either using alcohol to “reward” herself when projects were completed or, more often, drinking to de-stress after a long day. Initially, she had been able to perform well at work and had advanced in the firm, but additional re- sponsibilities brought additional stress, and her drinking increased steadily until she was drinking daily. From ages 24 to 30, she estimated that she drank a bottle of wine daily. Her work eventually suffered as a result—excessive sick days, missed dead- lines, strained relationships with peers—and although she never drank on the job, she was ultimately fired for her poor performance. It was around this time that Re- becca first entered treatment for her alcohol use with the outpatient detoxification and her stay at a sober living house. After treatment she had been able to remain so- ber only for a few weeks at a time and had not accessed any formal treatment, al- though she did intermittently attend Alcoholics Anonymous (AA) meetings.
Rebecca noted that she had always struggled with intense anxiety. She had been told that she was an anxious child, and she remembered feeling the scrutiny of others and constantly worrying about saying and doing the “right” things. This intensified when she was in the fourth grade and her family moved to a new town; her anxiety over being “different” and the “new kid at school” made her awkward around her peers and a target for teasing. Her anxiety persisted into adulthood, and although she was able to form close friendships, she still felt overwhelmed by new social situations. Her anxiety was not isolated to social situations but also en- compassed worrying about school, work, bills, and so on. She noted that she often would have difficulty sleeping because she was worrying about things that had happened during the day and making plans for the next day. She felt that her mother, whom she most resembled, also had a “nervous” temperament and was known in the family as a “worrier,” although she had never been diagnosed with any formal psychiatric illness. With respect to other family history, Rebecca’s sister had depression and was taking medication, and Rebecca’s father and grandfather had both been alcoholics. Rebecca was open about the fact that she found alcohol very effective in quelling her anxiety and that she was concerned that the signifi- cant stressors she was facing (lack of employment and independent housing and her recent breakup) would trigger her to relapse.
Rebecca also reported frequent mood lability—at times she could feel “good...almost happy” but then very suddenly become tearful or angry—with
fluctuations from day to day rather than sustained periods of mood change. She felt that most of the time her mood tended toward a depressed state; she had had one brief observation period about 2 years previously when she reported wors- ened depressive symptoms and passive suicidal thoughts. She was discharged at that time with a diagnosis of major depressive disorder and had attended follow- up care with individual therapy and selective serotonin reuptake inhibitors (SS- RIs) for a few months before discontinuing. Rebecca found therapy somewhat helpful but was unable to tolerate medication because she thought that it made her “too nervous.” She denied periods of decreased need for sleep but did ac- knowledge difficulty getting to sleep because of anxiety. She had never had any psychotic symptoms (no hallucinations or grandiose delusions) or periods of euphoria. She did report sometimes spending more money than she had and ne- glecting to pay bills and loans in favor of buying presents for others; in a family meeting later in Rebecca’s course her mother related that Rebecca had once taken a seemingly impulsive trip cross-country and had to have her parents buy a return ticket for her. While in the sober living house, her anxiety and depressed mood did not improve, and she continued to have frequent mood swings.
Rebecca was initially reluctant to start medication but ultimately decided that she had felt “not normal” for such a long time that “I’m willing to try any- thing.” After a discussion of the risks, benefits, and alternatives to lamotrigine, she was started on a low dosage on the rehabilitation unit. She also was contin- ued on buspirone 10 mg orally three times a day, which she had been prescribed by her primary care physician for anxiety; this was later discontinued because she had found it helpful only initially.
In individual sessions, Rebecca discussed further her fear that her anxiety would lead her to relapse. She admitted that after two drinks she sometimes felt that her worries were diminished and she was “almost normal.” Because of this ef- fect, she believed she was able to be more social and more functional, and she was fearful of giving this up. She was ambivalent about whether drinking helped her be more functional in other realms; she still believed that it had helped her man- age work stress more effectively but admitted that when her drinking increased to daily, it eventually impaired her ability to work. Her therapist did not challenge her on these assertions and instead helped her highlight her reasons for wanting to quit drinking and consider what it might be like to lose these seemingly posi- tive effects from alcohol. On further discussion, Rebecca realized that it had ac- tually been quite some time since she had seen any of her friends with whom she was previously close and that in the latter stages of her alcohol use disorder she tended to be fairly isolative. She also worried about the effect that alcohol had had on her health and was quite rattled by her withdrawal seizure, which was one of the more direct precipitants that led her to seek treatment.
Rebecca did well over the course of her rehabilitation stay. She was an active participant in groups and worked in individual sessions on developing coping skills to manage anxiety. She attended AA groups while on the unit, but through- out her stay she questioned whether she could follow an abstinence-only approach long term. She did feel that early in her sobriety she would aim for abstinence. Her lamotrigine was titrated to a dosage of 50 mg orally twice daily, which she tolerated well. Rebecca reported a decrease in her overall level of anxiety and experienced somewhat improved mood with fewer mood swings. She was discharged after 28 days to continue treatment in an intensive outpatient program.
Discussion
A first step in planning a course of treatment may be helping the patient select a treatment setting. Fortunately for Rebecca, New York City has a number of op- tions available. For patients requiring detoxification (i.e., patients using alcohol, benzodiazepines, or opioids), inpatient and outpatient detoxification services are available. For Rebecca, the main factor that drove her choice of inpatient de- toxification was her alcohol withdrawal seizure, which occurs in about 3% of pa- tients with alcohol dependence, thus necessitating closer monitoring and medical support services during detoxification. She then transitioned to inpa- tient rehabilitation because of her recent decline in functioning (lost job, boy- friend, housing) and suspicion of psychiatric comorbidity. Other treatment options available included an intensive outpatient program (could have been ap- propriate as well), long-term residential rehabilitation (likely too intensive), or outpatient treatment in a clinic setting (likely not intensive enough).
An important facet of this case was the fact that Rebecca had psychiatric symptoms that could have been related to her alcohol use or could have indi- cated a co-occurring psychiatric illness. Mood and anxiety disorders frequently co-occur with alcohol use disorders; results from the National Comorbidity Survey show 12-month prevalence rates of 12.3% and 29.1%, respectively, in al- cohol abuse and 29.2% and 36.9% in alcohol dependence (Petrakis et al. 2002). In Rebecca’s case, she was experiencing ongoing intense anxiety, mood swings (with mood more frequently depressed than elevated), and difficulty with sleep; she also had had periods in which she was spending more and engaging in im- pulsive behavior. She had had at least one major depressive episode in the past warranting a brief psychiatric observation. Determining whether her symp- toms were substance induced or due to a co-occurring disorder required con- sideration of the time-course of the development of her symptoms and evaluation of her symptoms during previous periods of sobriety. Given that she described her childhood temperament as anxious, with intensification due to social upheaval in the fourth grade, it is clear that her anxiety preceded her sub- stance use (which did not begin until age 15 and did not worsen to substance use disorder until her twenties). Depressive symptoms emerged in her college years and did not respond well to SSRIs. Rebecca’s mood lability, which per- sisted even during a 3-month sobriety, her history of impulsive spending, and her cross-country trip made the team consider a diagnosis of bipolar II disorder. Lamotrigine helped stabilize her mood and diminished her anxiety enough for her to more fully participate in the treatment program available.
Although Rebecca did not choose to start a medication for the treatment of al- cohol use disorder, there are three medication options available that are approved by the U.S. Food and Drug Administration (FDA). Of these medications, two—
acamprosate and naltrexone—are considered to have an “anticraving” effect, and the third—disulfiram—discourages patients from drinking by causing adverse reactions if patients drink while taking it. Disulfiram, which was the first of these medications available, acts to block the breakdown of acetaldehyde by aldehyde dehydrogenase; patients who drink while taking this medication experience nau- sea, flushing, palpitations, and headache. Disulfiram might be a good choice for patients who are motivated and have a supportive network to help with directly observed treatment. However, it does not reduce cravings, and patients can dis- continue it and resume drinking within 2–3 days. Acamprosate, an N-methyl-D-
aspartate modulator, and naltrexone, an opioid antagonist, both help to reduce cravings when taken daily. Although there is evidence supporting the efficacy of both, a large randomized controlled trial comparing the two showed superior ef- ficacy for naltrexone (Anton et al. 2006).
Regarding Rebecca’s attitude toward recovery, it is important to note that her therapist employed an empathic, patient-focused approach that is the spirit of motivational interviewing. Rather than confront her with reasons that she should be sober and the negatives that had come from her drinking, he allowed Rebecca to speak about some of the positive aspects she found from drinking and acknowl- edged that this would in some ways be a loss for her. Rebecca herself acknowl- edged that there were negative aspects to drinking, and her counselor worked with her to highlight these reasons for change and to enhance her motivation. This helped better engage her in treatment, created an empathic space for Rebecca in which to work on change, and prepared her for the next phase of treatment.